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Personal Care Assistance

Provider time and activity documentation

Page posted: 11/04/13

Page reviewed:

Page updated:

Legal Authority

Minn. Stat. §256B.0659, subd. 12, 28 (4), 24 (2) (3) (5) (7)


PCA time and activity documentation: A written document recording PCA services provided to assist a PCA recipient.


A PCA must document all time and activity provided to each PCA recipient daily. Documentation:

  • • May be Web-based, electronic or paper
  • • Must include all required components
  • Providers use the documents to bill Medical Assistance for authorized PCA services. Medical Assistance only pays for PCA time and activity authorized and described in the care plan.

    Required Components

    Agencies may:

  • • Use PCA Time and Activity Documentation (DHS-4691) (PDF) or
  • • Develop their own documentation format
  • All PCA time and activity documentation must contain at a minimum the following:

    Provider information: Agency name, phone number

    Recipient information: Name, Minnesota Health Care Programs identification (MHCP ID) number or date of birth, dates and location of recipient stays in hospital, care facility, or incarceration

    PCA information: Name, Unique Minnesota Provider Identifier (UMPI)

    Dates of service: Day, month and year of each service in consecutive order

    Service information: Arrival and departure times of each visit, including AM and PM notations

    For shared services: Ratio of staff to recipients and location of visit.

    All daily activities provided: (same or similar categories): Dressing, grooming, bathing, eating, transfers, mobility, positioning, toileting, health-related needs, behavior observation and redirection

    Instrumental Activities of Daily Living (IADLs): (not allowed for recipients under age 18) including: Light housekeeping, laundry, meal preparation, other

    Total Time: Daily total time and total for timesheet

    Fraud statement: Time and activity documentation must include a fraud statement. Directly above signatures, include the following language:

    It is a federal crime to provide false information on PCA billing for Medical Assistance payment. Your signature verifies the time and services entered are accurate and that the services were performed as specified in the PCA care plan.

    Acknowledgement and signatures: The recipient should draw line through documented dates and times when services were not received. This is not required for Web-based or electronic documentation.

    Required signatures: Recipient/responsible party and PCA

    Date(s) of signatures: Date(s) the form is signed by each party

    PCA Provider Agency Responsibilities

    Provider is responsible to make sure time and activity documentation is:

  • • Separate for each recipient receiving shared services
  • • Filed in the person’s health record
  • The agency is responsible to:

    1. Verify documentation of each PCA’s hours worked.
    2. Pay PCAs based on actual number of hours of services provided.
    3. Have a template with English translation available when using time and activity documentation in another language.


    PCAs must submit PCA time and activity documentation to the provider at least monthly.

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